Med Errors

[UM Review RN]

For our collective benefit, list some of the med errors you've seen committed or caught before they were committed.

The only rules are:

1. No blaming.

2. No naming names.

3. State what the error was.

Examples:

1. Mag and KCl hanging without a pump. ---Both need to be administered on a pump.

2. Regular insulin, pulled up in mg's, not units ---Self-explanatory.

3. Digoxin 0.125 mg po qd ----Given with an apical HR of 42.

4. Order for Vistaril IV ---Never give Vistaril IV.

5. Lopressor 25 mg po bid, 1 tab ----Pt. got 50 mg. because this med only comes in 50 mg tabs and should've read "1/2 tab."

6. PRBCs hung over the 4 hour limit. PRBCs piggybacked into ABTs. ---PRBC total hang time may not exceed 4 hours. This might include time taken from the blood bank in some facilities. ---Never piggyback anything into PRBCs.

7. PRBCs not hung for over 24h with a Hgb of 6.8.

8. "Demerol 100 mg. IVP q2h prn" --Classic case of "too much, too soon."

9. "Percocet 1-2 tabs po q4h prn, Darvocet N-100 1-2 tabs po q4h prn, Tylenol ES gr. X q4-6 h prn" ---Tylenol can potentially exceed 4 gm/day max.

10. Dilantin piggybacked into D5. ---NS yes, D5 no.

[natalie1488]

Just last week a surgeon gave me an order for iv vistaril. Pharmacy then called me to say it is only a last resort route due to extravasation(sp?)

They said it may be given in a dedicated line with fluids running at a fast rate, but never into a saline lock. Needless to say I called back the doc for an IM order. natalie

UOTE=stevierae]You can't give Vistaril IV? Huh, it SEEMS like we used to give it all the time--in combination with Demerol--in very early labor for pain relief (granted, this was back in the '70s, before anyone had even HEARD of epidurals.) Maybe my memory is faulty, and we gave it IM.

I can't say I've even seen Vistaril used in any operating room setting, even IM, since Versed became available--but I have heard it is still used in ER settings for migraines--perhaps also in combination with Demerol.

What's the reason that it should not be given IV?

OK, maybe 5 years ago, I was circulating on a D&C for retained placenta. We had a Pitocin drip going to control the resultant post-partum hemorrhage, but her uterus remained boggy, and just wouldn't clamp down.

The anesthesiologist resident attempted to give Methergine IV. I stopped him and offered to give it for him I.M. in the deltoid, (and did so) because I was trained to never, ever give Methergine I.V.--as its effect is on the smooth muscle of the uterus, it should be given I.M., and, in fact, since the lady was already up in stirrups undergoing a D&C, the ideal route would have been to have the surgeon inject it with a spinal needle directly into the uterus, or even paracervically.

Now, I've since learned that you CAN give Methergine I.V. but it's not recommended except as a last resort, because it can preciptiate a hypertensive crisis or even a CVA. Anresthesiologists tend to give everything rapid IV push, and I shudder to think what this lady's outcome would have been had he proceeded to do so.

How about the rest of you? Have you ever seen Methergine given I.V.? Could it have just as easily been given I.M. in the situation in which you saw it done, and did the patient suffer an acute hypertensive crisis?

We also had to give this lady Hemabate and transfuse her.

[jen42]

My God.

Sorry, I'm a new nurse too. This is blowing my mind, some of it. I actually just made a med error, omitted a med and it got delivered late, luckily it wasn't too big of a deal. And of course I live right near Virginia Mason, where someone injected cleaning fluid into a patient and they died. (Not me, thank God, thank God, thank God.)

So what *happens* to these nurses? It seems like even for the most gross errors nothing happened? Do they get fired? Do they get educated? Do the patients get informed? Curious what the rules are.

[SmilingBluEyes]

God NO, NO methergine IV ever. Never have seen that.

[Q.]

Pitocin IV set up to be given without being piggy-backed to Lactated Ringers.

Caught before administered.

Procardia almost given instead of a prenatal vitamin.

Caught before administered.

[Spidey's mom, ADN, BSN, RN]

New nurse in OB on her own after orientation - same scenario as Suzy. Pitocin induction with no mainline of LR. I got her some LR quickly without scaring the patient.

steph

[SheaTab]

OB... new nurse on orientation, started pitocin drip to gravity. Her preceptor told her to start the pit low, so she did, just not on a pump. Of course, the patient ended up in the section room for fetal distress.

[SmilingBluEyes]

..............and they want to replace LPN/LVN with CMA's and other unlicensed people........

anyone see a problem here???

[Spidey's mom, ADN, BSN, RN]

..............and they want to replace LPN/LVN with CMA's and other unlicensed people........

anyone see a problem here???

Having come to nursing later in life without any kind of medical knowledge I have to say I continue to be amazed and dismayed at the amount of med errors.

steph

[SmilingBluEyes]

I am too, Steph. It is scary....and sobering.

[canoehead, BSN, RN]

Even though some of these med errors astonish me I learned long ago to never assume that I would never make the same mistake. I AM that stupid, and sometimes that careless, especially when busy and overconfident. Luckily I've caught most of my own serious errors, and the one time I didn't I confessed immediately and the patient made it through.

I think the important message of this thread is that there but for the fear of God goes every one of us, we can't assume we wouldn't screw up just as stupidly. If you keep that healthy fear you will be a much safer nurse.

[dazzle256]

For our collective benefit, list some of the med errors you've seen committed or caught before they were committed.

The only rules are:

1. No blaming.

2. No naming names.

3. State what the error was.

Examples:

1. Mag and KCl hanging without a pump. ---Both need to be administered on a pump.

2. Regular insulin, pulled up in mg's, not units ---Self-explanatory.

3. Digoxin 0.125 mg po qd ----Given with an apical HR of 42.

4. Order for Vistaril IV ---Never give Vistaril IV.

5. Lopressor 25 mg po bid, 1 tab ----Pt. got 50 mg. because this med only comes in 50 mg tabs and should've read "1/2 tab."

6. PRBCs hung over the 4 hour limit. PRBCs piggybacked into ABTs. ---PRBC total hang time may not exceed 4 hours. This might include time taken from the blood bank in some facilities. ---Never piggyback anything into PRBCs.

7. PRBCs not hung for over 24h with a Hgb of 6.8.

8. "Demerol 100 mg. IVP q2h prn" --Classic case of "too much, too soon."

9. "Percocet 1-2 tabs po q4h prn, Darvocet N-100 1-2 tabs po q4h prn, Tylenol ES gr. X q4-6 h prn" ---Tylenol can potentially exceed 4 gm/day max.

10. Dilantin piggybacked into D5. ---NS yes, D5 no.

New grad trying to be helpful walks past a room with IV beeping. She adds more volume to the pump so the rest of the IV fluid could be infused. It was Mannitol.

[SmilingBluEyes]

Even though some of these med errors astonish me I learned long ago to never assume that I would never make the same mistake. I AM that stupid, and sometimes that careless, especially when busy and overconfident. Luckily I've caught most of my own serious errors, and the one time I didn't I confessed immediately and the patient made it through.

I think the important message of this thread is that there but for the fear of God goes every one of us, we can't assume we wouldn't screw up just as stupidly. If you keep that healthy fear you will be a much safer nurse.

point well-taken. Another reason to respect meds and the process of administrating them. Another reason I say, if you want medications administered, you hire a NURSE. We are not infallable, but we do at least realize the consquences and implications of every med we give.